Last week, I had the pleasure to be invited to give two teaching presentations to the residents in the Section of Plastic Surgery of the University of Michigan Medical Center in Ann Arbor. The talks, about cosmetic surgery and the basics of running a practice, were well received by the residents. Dr. Bill Kuzon, the Chief of the Section and a distinguished Professor of Surgery, was an extremely gracious host, and went out of his way to make me feel at home.

While I was there, I had a chance to chat with the faculty members and see what’s new in academic practice. I was particularly pleased to learn that new research from U of M about preventing DVT’s after abdominoplasty completely supports what we’ve been doing in our practice. Also, Dr. Wilkins at U of M is using fat grafting to the breast for reconstruction after cancer, something that we are also starting to work with in our practice. I had a chance to visit with Dr. Paul Cederna’s lab group, who are working on getting nerve impulses to control high-tech prosthetics for combat-wounded amputees. The stuff they are doing is simply amazing.

The size of the U of M medical center is overwhelming, even bigger than when I was there 15 years ago …it covers about 12 city blocks. The new children’s hospital set to open this fall, will be the largest in North America, with over 1 million square feet of area.

All in all, a successful trip. But brrrrr……it’s cold up there!

If you were up early this morning, you might have seen yours truly on channel 6, at 6:45.

I had been interviewed by WKMG’s Jessica Sanchez on Monday. We discussed the controversy regarding “awake breast augmentation” surgery. We’ve discussed that topic at length here in this blog.

Unfortunately, only a very short bit of the TV interview was used. They didn’t even mention one of the most important points: that many of the providers who use this technique are not board-certified plastic surgeons, don’t have hospital privileges, and can’t get proper anesthesiologists or CRNA’s to work with them. Some don’t even have any surgical residency training at all – they just took a weekend course or two.

It’s a huge legal loophole. And it’s bad news for Floridians.

Patient safety is my #1 priority. Having an anesthesiologist present, to monitor all the vital signs and make sure you are comfortable and breathing safely is a key part of patient safety. I think that skipping this, just to save a little money, is foolishly cutting corners in a dangerous way.

What are your thoughts? Please post a comment….
We’ll post the link to the Channel 6 interview as soon as we can.

Here is a partial list of products that are awaiting FDA approval. All of them could be significant improvements over what we have now. And these are just a few examples…

Fillers: Belotero by Merz, and Aquamid by Contura

Botulinum toxins: PurTox by Mentor

Breast implants: “gummy bear” form-stable implants – both Allergan and Mentor

Fat-grafting: Celution by Cytori for stemcell-assisted fat transfer

Body-contouring: radio-frequency assisted liposuction by Invasix; Focused non-invasive ultrasonic fat melting by Ultrashape.

All of these have been featured at the “Hot Topics” sessions at the various ASPS or ASAPS meetings, and many have been discussed here in our blog. The approval of even two or three of them could significantly change the way things are done here in the U.S.

We’ve been waiting for a “yes” or “no” answer on the gummy bear implants, for example, since 2007. And yes, these products are all available in Europe…

It turns out that it’s more than just the skin and facial fat that undergoes changes as our faces ages. There are changes in the actual shape of the underlying facial skeleton, too.

The most recent issue of PRS has an article on this topic, in which CT scans of the facial bones in young, middle-aged, and older age groups were compared. The results: there are a number of significant structural changes that occur in all areas of the face as we age. Overall, the facial skeleton loses volume as we age (which we knew), but more so in particular zones: the eye socket, the midface and the mandible (jawbone).

I was amazed by the CT images showing the change in shape of the eye socket. Both the upper rim and the lower outer rim of the orbit seem to melt away over the years, significantly changing the shape of the eye socket, and making it wider, longer and larger in area. Aging also affected the bones of the middle part of the face (maxilla) and the mandible in visually obvious ways.

(Image from Aging of the Facial Skeleton: Aesthetic Implications and Rejuvenation Strategies. Robert B. Shaw, Jr., et al.)

What does this mean? Plastic surgeons need to remember that the bony framework changes too, as we age. It’s not just about tightening up the skin, or adding volume to the face with fat or fillers. To help make someone look more youthful, we should analyze the patient and think about whether or not the facial skeleton needs to be corrected, in addition to looking at skin laxity or the loss of facial fat, like we usually do.

Maybe that blepharoplasty (eyelid tuck) would look even better if we put in a small implant to restore the shape of the bone to its original youthful contour. Dr. Flowers (in Honolulu) has been doing this for years – maybe he’s on to something!

CNN Cancer survivor's own fat gives her new breastsCNN has done a nice human interest story on a lady who had bilateral breast reconstruction after mastectomy and radiation therapy using a fairly new microsurgical technique called the S-GAP flap. The link is here. It’s good to get the word out about these newer options for breast cancer patients.

There are several important “teaching points” about this story:

1) Even today, many breast cancer patients don’t realize that breast reconstruction is possible and available to them. A 2009 survey from the American Society of Plastic Surgeons found that 7 of 10 women don’t fully understand their options for breast reconstruction after mastectomy. Breast reconstruction after mastectomy is covered by all health insurance plans – by law.

2) There are multiple methods of performing breast reconstruction. For the lady in the CNN article, since she had radiation therapy, most experts recommend some form of autologous tissue reconstruction (using your own tissue) rather than using an expander or implant. While radiation can be quite effective at sterilizing any remaining cancer cells, it also has permanent side effects on the tissue. All surgeons know this, but few radiation oncologists seem to discuss it with their patients!

3) Although the article made it sound a little like she had some form of fat injection to the breast, it is probably more likely that she actually had a microsurgical tissue transfer called an S-GAP flap (explained here). This is a relatively new technique, developed around 1993, in which a small blood vessel and its attached fat and skin is microsurgically transferred from the buttock area to the breast, to bring new tissue and a new blood supply to the reconstructive site. It’s a pretty cool method!

4) Even once the cancer has been treated, and reconstruction has been finished, that doesn’t mean that cancer survivors can let down their guard. Studies show that we really have to be on the look out for a sneaky recurrence of the disease for up to 20 years!

Thanks CNN, for spreading the word about this reconstructive option for breast cancer patients.

You’ve heard about stem-cell enhanced fat grafts for rejuvenating the face and the hands…but here’s a new & very cool idea: stem cells to fix an ailing heart.

Here’s the concept: Do some liposuction, and isolate out the small percentage of fat-derived stem cells from the rest of the fat enzymatically. Take these stem cells, and inject them (carefully!) into the heart muscle. The stem-cells then go on to repair the damaged heart muscle, hopefully helping the heart function better, and improving the patient’s symptoms and quality of life.

In the United States, more than one million patients have a severe form of heart disease, known as “no-option chronic myocardial ischemia” with a 10 year mortality rate exceeding 20% and an annual healthcare cost of more than $10 billion. If the idea works, it would be a huge step forward for these patients.

A recent multi-center, 27 patient, double-blind, placebo-controlled European study known as “PRECISE“, looked at this very idea, and the results were recently presented at the American Heart Association meeting. And they are very promising. The patients selected really had no other option, other than cardiac transplantation. As part of the procedure, a small amount of fat tissue was removed with liposuction from each patient’s abdomen. The stem cells were then extracted, and injected into the muscle of the left ventricle.

The researchers found that the stem-cell treated patients not only had a lower cardiac mortality rate over the course of the study, but that they could perform more physical activity after the treatment, and that the heart had a higher functional capacity and better maximum oxygen consumption (reflecting a higher work capacity) when compared to untreated control patients.

Impression: very exciting stuff! Sure it’s a small study, but if it pans out in larger trials, this could be a major breakthrough. Soon, maybe we’ll be seeing the plastic surgeon helping out some CCU (coronary care unit) patients with liposuction for stem-cell harvesting.

Ask anybody what they worry about when they are thinking of having surgery, and I’m willing to bet that answers like “I’m worried that I’ll be in pain or be nauseated” are near the top of the list.

What if I told you that, with improved medications prior to surgery, we could make this a lot better than traditional methods? Interested? You betcha!

Anesthesiologists and surgeons have been doing a lot of research on this area, to determine the best types of drugs to reduce post-op pain. And the answer isn’t always “just give more”, because the side effects of nausea, vomiting, sedation and respiratory depression from opioids like morphine, fentanyl or demerol can start to become problematic. It turns out that the combination of several different strategies works best. Technically, this is called “multi-modality treatment for postoperative analgesia”. (Impress your friends with that phrase!)

Interestingly, a medication used for years as an anti-epilepsy agent, called gabapentin, is a real winner for ambulatory surgery patients. One dose given pre-operatively has been proven in multiple studies to reduce post-op pain, reduce the need for opiate medications post-operatively, and reduce the incidence of nausea and vomiting after surgery.

Also, a non-steroidal anti-inflammatory medicine (NSAID) called diclofenac has be proven to be helpful in reducing post-op pain and swelling. Unlike many other NSAID’s, this one doesn’t have a significant effect on platelet function, so it’s OK to take at the time of surgery.

We’re in the process of switching over to this improved pre-op combo. By reducing post-op pain, patients will be obviously have an easier time with their recovery. By reducing the need for strong narcotics, they’ll have fewer side effects.

Should be a winner for everyone!

The US Food and Drug Administration (FDA) has asked that propoxyphene, (brand names Darvon and Darvocet) be removed from the US market. The decision will also affect generic manufacturers and the makers of propoxyphene-containing products.

At a press conference last week, Dr Gerald Dal Pan, director of the FDA’s Office of Surveillance and Epidemiology, said “For the first time, we now have data showing that the standard therapeutic dose of propoxyphene can be harmful to the heart.” Side effects of cardiac arrhythmias and other electrical disturbances were noted.

The FDA is advising healthcare professionals to stop prescribing propoxyphene. Patients who are currently taking the drug should not abruptly halt their medication but should contact their physician as soon as possible to discuss switching to another pain-management therapy.

“Long-time users of the drug need to know that these changes to the heart’s electrical activity are not cumulative,” Dal Pan added. “Once patients stop taking propoxyphene, the risk will go away.”

Propoxyphene is an opioid typically used to treat mild to moderate pain. It was first approved by the FDA in 1957. It is sold by prescription under various names alone or in combination with acetaminophen.

A phased withdrawal of propoxyphene is already under way in Europe. The European Medicines Agency made that decision in June 2009.

While it seems hard to imagine today, back before the early 1980’s, plastic surgeons didn’t really have any reliable injectable products to use for wrinkle correction or lip enhancement. When Zyplast and Zyderm arrived in the early 80’s, a new generation of of non-surgical corrections via injectable fillers became possible. These bovine-collagen fillers weren’t by any means perfect – they required skin testing, had a potential for allergic reactions, and didn’t last all that long. Still, they caught on like wildfire, and were used by millions worldwide with reasonable results most of the time.

Today, we hardly use Zyplast, Zyderm, Cosmoplast and Cosmoderm anymore. They have long been replaced by better products, like Juvederm and Restylane. The newer HA gel products are easier to use, are available in a variety of consistencies and formulations, don’t need skin testing, have a far smaller risk of allergic reactions, and can be “erased”, if need be, by an injection of hyaluronidase. It’s a big improvement.

Earlier this year, Allergan announced that the old generation of collagen fillers would no longer be distributed at the end of 2010, due to lack of demand. (Allergan actually stopped production of the products in 2009, but had enough inventory in stock to meet the projected demand for another year.)

Should you be worried? No. In addition to Restylane, Perlane, Juvederm, Juvederm Plus, Prevelle Silk, Radiesse, Selphyl, Sculptra and others, new filler agents like Belotero are just around the corner. You’ll still have plenty of excellent choices. Technology has advanced, and we have considerably better choices now.

1. The new e-book “Plastic surgery 101: What to know before your consultation” is now completed and available. Yay! It will be a free download for patients that schedule a consultation, and I hope everyone will find this guidebook to be educational in nature. If our established patients would also like to get a copy, just send us an email, and we’ll be delighted to send it to you. Feel free to share it with your friends, too.

2. We’re also working on an updated version of our iPhone app “Plastic Surgery with Dr. Fiala”. Not only will this include the new e-book, but various YouTube video segments of ours. It will also have some enhanced functionality and appearance.

3. I’m in the process of finishing up a second e-book. This one is about breast augmentation surgery, and covers dozens of frequently asked questions that prospective patients like answered before surgery.

I find that the better educated patients are about surgery before they have it, the happier they are afterwards. That’s one reason why we are so pro-education. Plus…I like to teach.

Remember our Veterans tomorrow!

Plastic Surgery In Florida